The Board of Healthcare Funders of Southern Africa (BHF) recently investigated the distribution of service providers in both the public and private sectors across South Africa. The research not only included general practitioners (GPs) and specialists, but also allied health professionals such as medical technologists, radiologists and pathologists.

Older practitioners moving to private sector

The report focused specifically on professionals registered on the practice code numbering system (PCNS) from January 2000 to December 2017. For a healthcare provider to claim from a medical scheme they need to be registered on PCNS. “A 52% increase in active healthcare professionals was noted, from about 36,000 in 2000 to 54,800 in 2017. Surprisingly, however, this increase occurred in tandem with a higher average age in most disciplines. This unexpected observation is worrying as it suggests that there has been an increase in the number of older professionals moving from state facilities to the private sector,” says Charlton Murove, head of the BHF’s research unit and the author of the report.

The private sector services medical scheme beneficiaries, numbering 8.9-million in 2017, and other patients accessing health services through paying cash or via insurance products. “In 2000, there were 7-million beneficiaries, so there has been an increase over the years. But there has clearly been an even larger increase in healthcare professionals in the private sector (52% vs 27%).”

Geographical distribution

The report found that the distribution of healthcare providers is disproportionate in terms of geographical location and population needs. Gauteng and the Western Cape have more per 10,000 population compared to more rural provinces such as Limpopo and Mpumalanga. This disproportionate distribution is acute in more specialised disciplines. The provider numbers in the latter provinces are well below the national Department of Health targets of healthcare providers per 10,000 population. This disproportionate distribution is evident in both the private and public sectors. Over and above this, there is a disproportionate number of providers practising in the private sector compared to the public sector. This leaves a high burden of care for those in public facilities. “The increasing number of providers in the private sector and the aforementioned increase in their average age suggests two things; training programmes to recruit new providers are inadequate and the public sector has lost staff to the private sector over the years,” says Murove

Exit rates

Those registered on the PCNS do not seem to stay in practice for long. A high number leave before reaching retirement. About half of male healthcare professionals de-register their PCNS numbers before they reach the age of 50. The rates of exit are significantly higher among women; about half leave private practice before the age of 45. “For a country below its target number of healthcare providers per 10,000 population, this observation is very worrying,” he says.

Rates of exit of men do not differ much by provincial location. Gauteng experiences the highest number of exits. Women’s rates of exit differ markedly by provincial location, however, with Limpopo experiencing the highest rates and the Western Cape the lowest.

Rates of exit also vary according to discipline. Male healthcare providers practising in laboratories, medical technologists, pathologists and radiologists had the highest rates; 23% higher than male GPs. Specialists (anaesthetists, medical and surgical specialists) had the lowest – about 50% lower than GPs.

Similar observations were made for women. The differences across disciplines were much wider, though – those practising in laboratories had exit rates 41% higher than female GPs, while specialists’ rates of exit were about 60% lower than those of GPs.

Training as a lever

But while the maldistribution of human resources and the rates of exit are alarming, the report also made some positive findings. “The number of GPs in private practice is 15.69 per 10,000 population, which is higher than the Department of Health target of 3.66 per 10,000 population. This presents an opportunity for both medical schemes and the state, as GPs may be contracted into arrangements where they serve a targeted population group. The government’s plans for rolling out NHI are possible given the number of GPs in the private sector – if they can be contracted to service the rest of the South African population. (In Gauteng and the Western Cape, even the number of specialists is above target.)

“The training of healthcare professionals should be considered as a lever to improve the provider/patient ratio, especially among specialists. Greater focus must be placed on increasing the number of specialists. The increasing average age points partly to a small base of new providers entering from training facilities,” concludes Murove.